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User’s perspective of landscape existence in healthcare buildings

Authors Alanoud Alansari Asma Alawirdhi Asmaa Ramadan Elantary

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User’s perspective of landscape existence in
healthcare buildings

Asmaa Ramadan Elantary, Alanoud Alansari & Asma Alawirdhi

To cite this article: Asmaa Ramadan Elantary, Alanoud Alansari & Asma Alawirdhi (2021) User’s
perspective of landscape existence in healthcare buildings, HBRC Journal, 17:1, 519-532, DOI:

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2021, VOL. 17, NO. 1, 519–532

User’s perspective of landscape existence in
healthcare buildings
Asmaa Ramadan Elantary                      , Alanoud Alansari and Asma Alawirdhi
Interior Design Department, Jubail University College, Jubail Industrial- Saudi Arabia,
Kingdom of Saudi Arabia

    Landscaping and greenery are some of the major factors that play a vital role in
    human being’s phycology and how one feels. It also affects people’s wellbeing
    and could improve their health. This made landscaping a primary consideration
    in places that focus on recovery and healing, such as hospitals. By showing this
    relationship between health and landscaping, the research goal is to improve
    and control the hospital buildings, which will be built or renovated in the future,
    especially in Saudi Arabia. The focus will be on buildings’ landscaping design
    and greenery to achieve high functionality spaces. This paper will detail the
    relationship between landscape as well as greenspaces in healthcare buildings.
       A survey was published for patients in different hospitals in Saudi Arabia to
    analyze related thoughts and investigate the effectiveness of landscape exis­
    tence on the patient’s recovery. Additionally, particular case studies were
    examined and analyzed. The results revealed that users believe that healing
    centers’ landscape unequivocally influence patient’s wellbeing and seeing
    scenes around the site. Furthermore, landscape in healthcare buildings is
    neglected; some recommendations were given for particular green areas with
    percentages to help improving the current healthcare buildings alongside the
    upcoming ones.

ARTICLE HISTORY Received 27 July 2021; Revised 23 October 2021; Accepted 26 October 2021

KEYWORDS Landscaping; human wellbeing; psychology healing; greenery

As the world evolves, more interest is given to urban designs and greenery in
diverse types of buildings; this stemmed from aiming to improve the quality of
life by giving more thoughts into the design process to serve the occupants’
needs and thinking about future generations and their health. As a consequence,
landscaping becomes an essential part of the components of any building. It can
affect how people act and feel about the space in different ways and improve
their quality of life. Studies have shown a relationship between the landscaping

CONTACT Asmaa Ramadan Elantary          Interior Design Department, Jubail
University College, Jubail Industrial- Saudi Arabia,P.O. Box 10074, Jubail Industrial City 31961
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
520      A. R. ELANTARY ET AL.

and greenspaces on human beings’ health, as the World Health Organization
(WHO) defines health as ‘a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity’ [1,2]. It has also shown
that different types of greenery have a different impact on human beings’
resulting in a different way of thinking about designing according to the function
behind. Some of the examples that green spaces’ can affect our health is by
reducing stress and improving people’s mood [3]. As mentioned in the book:
Bringing User Experience to Healthcare Improvement: The Concepts,
Methods . . ., There are three elements of good design ‘Performance,
Engineering, The Aesthetics of Experience’ and this is applicable for any project
or item as these concerns how well it does the job and fit for the purpose; how
safe, well-engineered and reliable it is; and how the whole interaction with the
service is experienced as shown in Figure 1. This includes functionality, Safety,
and usability [4].
   Researchers also studied landscape effects in four Dutch cities (Utrecht,
Rotterdam, Arnhem, Den Bosch) where they questioned if health and green­
ery are related? And whether greenery existence moderates stress? The
answers have strongly concurred that greenery is related with health and
helps with stress [5]. This leads to a belief that landscaping should be
considered as a primary component of buildings’ design.
   On the other hand, a study done in the United States has shown
a remarkable association between emotional well-being (EWB) and green­
spaces by using a developed application that measures the happiness and
meaningfulness according to different activities included gardening. The
result showed that gardening is one of the top 5 among the 15 other activities
that were investigated [6]. Another study discussed how the greenspaces and
landscaping have accelerated the patients’ recovery process and how differ­
ent types of greens impact them by an experimental survey; the patients have
expressed their need for contact with nature [7]. A systematic map on the

                                 Performance    Engineering

                                      The Aesthetics of

Figure 1. The three elements of a good design. Source: Berkun.
Figure 2.AQ8 Research target and related questions.
                                                      HBRC JOURNAL
522         A. R. ELANTARY ET AL.

               The presence of green spaces and landscapes
                     helps to stay longer in the place.
                      80           74
                      50                             45
                      10                                          3              1             0
                                Strongly                                                  Strongly
                                                    Agree      Neutral        Disagree
                                 Agree                                                    Disagree
         No. of Responses          74                45           3              1             0

Figure 3.AQ9 Number of responses about the landscape presence and its relationship
with the time spent at the hospital premises.

            Your unwillingness to go to the hospital and see a
            doctor is related to the feeling that hospitals give
      Strongly Disagree        2
              Disagree                    12
               Neutral                         17
                 Agree                                          37
        Strongly Agree                                                            56

                           0       10          20         30    40       50          60   70         80
                               Strongly                                                   Strongly
                                                Agree          Neutral        Disagree
                                Agree                                                     Disagree
       No. of Responses           56                37           17             12            2

Figure 4.AQ10 Number of responses about users’ willingness to visit a particular
hospital site.

effect of green spaces on mental health have shown that there are some gaps
in the knowledge regarding methodological approaches, the range of obser­
vational studies have used cross-sectional data, so there resultant is not
showing if there is a causal relation between green spaces and mental health
nor the strength [8].
                                                            HBRC JOURNAL        523

Figure 5.AQ11 Cleveland Clinic, USA, Ohio.

   This information leads to thinking about the possibility to improve and use
landscaping as a part of the healing and recovery process of the patients in
hospital buildings, especially in Saudi Arabia as there are plenty of spaces and
prospective development. Also, it implies a query if this relationship is exist­
ing and prominent from the user’s point of view.

The relation between landscaping and hospital functionality
Landscaping has a major effect on people’s health specifically on hospitals
among different institutions, either physical, psychological, or social effect.
Outdoor areas in hospitals plays an important role as indoor spaces in the
process of healing to the patients.
   Physical effect is related to the healing process because it gives the
patients a positive effect and a chance to feel their well-being. Also, positive
effect on blood pressure, cholesterol levels and stress-reduction by interact­
ing and spending time in the nature [9].
   People prefer to spend time in hospital and healthcare spaces with a green
landscaping area due to its psychological effects on them because they have
the chance to choose between a social environment and a private environ­
ment depending on their psychology and need at that time. Green spaces
provide a social space for interacting with people in a better way that
enhances the healing process by the time [1].

Different types of greenery and its influences
As the types of greenery vary, their influence varies as well. Some of them have
a positive impact on human wellbeing and the environment, while others can
negatively affect users [10]. For example, some types can play an essential role in
improving air quality by purifying and reducing the humidity, leading to
a healthier environment for people to help with the general health condition.
                                                  A. R. ELANTARY ET AL.

Figure 6.AQ12 Royal Commission Hospital layout.
Figure 7.AQ13 Royal Commission Hospital location and land use.
                                                                 HBRC JOURNAL
526      A. R. ELANTARY ET AL.

   Other types of greenery help to improve the phycological condition of people
through their smell. For example, lavender helps to relax. Some studies have
shown that specific plants can help with stress, social cohesion, and mental
health [11]. These influences and factors could be used to the favor of improving
public health in several ways. One is through landscaping in hospitals.

Possibility of using landscape and greenery as part of the patients’
It may be the habit of seeing nature as a healer drawn from history’s way out.
In Europe, during the Monastic hospitals delivered in the Middle Ages with
fenced gardens of vegetation with the intent of completing the spiritual
transformation of patients. Nature’s role in bodily regenerate a better foot­
hold was increased in the 17th and the 18th century, the arrival of modern
research. Medicine recommended that the spread of infections was through
poisonous vapors in the air. This promoted designs for architecture that gave
new air attention and cross-ventilation. In Notes on Nursing, Florence
Nightingale (1860), Wrote on the significance of direct, fresh air Sunlight
and visual communication with nature to promote the body’s regeneration.
Healing gardens roles include opportunities for physical movement and
exercise, opportunities to make decisions, pursue privacy and a sense of
control, habitats that allow people to gather and enjoy social encouragement
and access to nature and other beneficial distractions, and reduce pain and
tension for patients suffering from incurable or chronic disease) [12].
    A study with a thesis showing that the link between humans and green plants
has existed since ancient times, and the number of studies focused on the
problem has recently increased. The presence of green foliage facilitates regen­
eration by triggering beneficial improvements, such as increased blood pressure,
improved heart function, enhanced muscle activity, and improved brain electrical
activity and it has shown that there are three separate patient groups on how
therapeutic hospital gardens should be designed: dementia, catastrophic, psy­
chiatric. It considered how and when planning a garden for each. The planner has
to resolve variations within these patient populations. Therapeutic gardens will,
in turn, encourage improved patient outcomes, as the study indicates [13].
    Other studies also revealed that keeping gardens esthetically appealing
will minimize discomfort, decrease the need for drugs, speed up the healing
process, and promote the journey to recovery [14,15]. There is a need to
address and discover knowledge about therapeutic gardens and how parti­
cular patients might benefit from their existence. A study shows how the
characteristics of each of the different gardens are sensitive to the environ­
mental preference factors of the Kaplans (coherence, legibility, mystery, and
complexity); to the four stress relief factors of Ulrich (movement and exercise,
                                                             HBRC JOURNAL        527

social reinforcement, sense of control, and natural distractions); and to other
factors defined as significant by the other case studies garden directors
(safety, security, and accessibility).
   The study analyzed plans that differ from each other in individual location
places with comparatively greater focus on characteristics. For example, all three
gardens have pathways: the material in the pathway varies in the dementia
garden at entry and exit points to alert the individual to move (i.e. an indicator of
going from outside to indoors); they are wide and circular in the disastrous
garden, and they follow a grid pattern in the psychiatric garden. Every garden
also contains a water feature: it serves to soothe in the dementia garden; it
primarily serves to distract in the disastrous garden. It mainly helps to provide an
opportunity for meditation in the psychiatric greenhouse. The dementia garden
emphasizes wall seats and benches; the fatal garden emphasizes planting
opportunities; the clinical garden emphasizes intimate seating and allows distinct
positions for private reflection. All three gardens provide mutual support,
although in very different ways. Finally, and importantly, all three gardens
emphasize sensory attraction as a way of achieving stress relief, diversion, and
pleasure (visual, auditory, tactile, and olfactory) [12].
   So, this paper aims at, investigating the user’s perception of landscaping
presence as a part of hospital functionality. In addition, the user’s opinion
about the possibility of using landscape and greenery as part of the patients’
treatment. In addition, an evaluation took place for existing hospital land­
scape at one of the leading cities in the Kingdom of Saudi Arabia.

The objective of this study is to show how people’s feelings and psychology in
the hospitals are affected by the existence of landscaping areas. The method
used is binary, where a survey that targeted the people living in a specific region
in the Kingdom of Saudi Arabia is held. In addition, other hospitals case studies
were examined. The study assumption is that landscaping is highly important in
hospitals and is considered as an essential part in enhancing the health recovery
and psychology of patients, hospital employees, and visitors.
    The information was collected by a survey with multiple-choice questions
and Likert 5-point scale that focused on showing the quantitative data of the
questions. Other descriptive data was collected by gathering observations
and people’s experience and opinions in open-ended questions. The survey
was conducted by a questionnaire designed by Google Forms Documents
website, which was then sent to people living in the region by social media
applications. People started answering the questions after 4 min from sharing
it. The survey had six Likert questions and two open-ended questions that
were answered by 124 persons.
    The two case studies were selected as follows: -
528         A. R. ELANTARY ET AL.

      First case study: the hospital which is rated the highest in patients’ evaluation

Second case study: the biggest hospital in Jubail Industrial City, Kingdom of
Saudi Arabia. This city is a leading city, which won the Arab Green City Award,
it has 1.5 million trees and 1.3 million square meters of grass.
    The shape below explains the paper target with relation to the method used.

By using the SPSS analysis program, the survey results revealed that the data
collected is reliable and the Cronbach’s alpha or coefficient alpha test value is
0.709 where survey results are connected and related to each other.
   Out of 124 responses a mean of 4.81 out of 5 strongly agreed that land­
scape areas have a major effect on people’s healing process and their psy­
chology when they visit the hospital. Besides, an average of 4.56 out of five,
which means strongly agreed as well, found that having landscape areas
within the hospital design helps them to value their stay meanwhile affected
the overall impression of the whole place.
   Not only the user’s impression about the place, but also 3.72 out of five
strongly agreed that the hospital landscape design can affect their decision in
choosing a particular healing facility. In the meantime, the participants strongly
agreed with 4.1 out of 5 that their judgment of a hospital is influenced by the
surrounding landscapes and the general location of the hospital building, which
in turn affects the user’s decision in going to a particular hospital rather than
another one. Participants also confirmed with 4.07 that their willingness to go to
the hospital and see the doctor is connected with the feeling the hospital
location, building design, and landscaping; give to them.
   Studies approved that landscape increase the comfort level and well-
being; hence, people appreciate and like to have and see garden elements
such as lawns, trees, flowers, and water features. The landscape plays a major
role in the recovery process, because the visual part is an important share in
the healing process, especially if it is connected to the things people see in
their daily life such as, a green and colorful landscape. This shows that land­
scape is really important in people’s life and reflects user’s awareness about
the importance of landscape in health-care buildings.

Case studies
Cleveland Clinic, USA, Ohio
One of the leading hospitals around the world is Cleveland Clinic in
Cleveland, OH. it was ranked as the second of the best hospitals in 2020
according to the U.S. News and World Report in the Best Hospitals Honor Roll,
                                                          HBRC JOURNAL        529

with national rankings in 14 adult and 10 pediatric specialties, including the
Department of Psychiatry. Since 1995, the cardiology program has been
ranked first in the country [16]. The hospital campus has been developing
and expanding over the years, yet it was well designed and proportioned that
it was known for its greenery and large use of landscape. To understand the
importance of space planning and its role besides the staff and the quality of
the services and other clinical equipment, the researchers have studied the
layout of the clinic and calculate the percentages of the facilities. the results
showed that the built area represented 31.82% of the total area, while the
landscape occupies around 48.32%, the remaining areas were either parking
slots or roads. this result highlights the importance of the landscape and
green area and its role in healthcare facilities.

Royal Commission Hospital, KSA, Jubail
Another hospital that is considered one of the main hospitals in the eastern
province in Saudi Arabia, is the Royal Commission Hospital in al-Jubail
Industrial city. It holds the JCI—Joint Commission International—accredita­
tion which is a certification given to hospitals that are recognized as a global
leader for health-care quality of care and patient safety along with other 5
different certifications [17].
   Yet, with all these services and such quality, the hospital environment was
not as welcoming and organized as the patient would imagine based on their
comments and survey feedback. after calculating the hospital areas with
relation to the site plan, it has been found that the built area represents
24.81% of the total space, while greenery and landscape area occupy only
5.48%, and the rest is devoted for parking and traveling through spaces in
addition to a lot of empty lands with potential to be designed as landscape
   As shown in the previous examples of the two hospitals, it appears that
landscape can be considered as a major part of the hospital’s effectiveness as
it touches the whole journey of treatment and its efficiency. Thus, it is
suggested investing and put more effort into the landscape and greenery
designing in hospitals in Saudi Arabia to improve and reach a greater level.
   As shown in Table 1, the built area is near in both cases, but the
landscaping area in the Saudi hospital occupies only one-tenth of the
devoted landscape area in Ohio hospital. Additionally, lots of spaces are
left without purpose. Based on the survey results in the previous section,
people do value the landscape existence and believe in its effect on the
medication process. Meanwhile, most of the leading hospitals neglect the
landscape presence and its importance as an effective part in the healing
530        A. R. ELANTARY ET AL.

Table 1. Comparison between the selected case studies.
                                    Built   Landscape     Remaining (parking slots or
                                    area       area                roads)
 Cleveland Clinic, USA, Ohio       31.82%    48.32%                19.86%
 Royal Commission Hospital, KSA,   24.81%     5.48%                69.71%

From the data that have been collected through the survey, and the results
analysis discussed in the previous parts alongside the aforementioned case
studies, it shows the possibility that landscape, and greenery are considered
a significant part of human wellbeing, and it has to be implemented in the
hospitals as a part of the treatment methods. This result can be supported by
the findings of the following points:
   As discussed, it is evident that plants and landscape can play an essential role
in human wellbeing, which led to think if it is possible to use it in the process of
helping the patient in hospitals to get better and implement it as a part of their
treatment. By investigating and seeing what people think about this, the survey
conveyed that it matters and affects people’s behavior and feeling about the
hospital if its landscaping is adequately designed; this proves the point that
states the possibility of greenery to affect how people feels in space, it is also
known that people’s spirits play a primary role in patient recovery.
   Furthermore, research titled” Effect of Hospital Landscaping on the Health
and Recovery of Patients” has studied this by investigating some hospitals
located in Pakistan. It has been made clear that patients who have access to
hospitals with well-designed landscaping show a remarkable recovery ratio
compared to others who have no access [1].
   Some leading hospitals in the kingdom have plenty of areas, but these
spaces are not oriented and designed for the sake of having landscape and
green areas. This in turn affected users’ perception and evaluation of local
hospitals. These spaces need reevaluation and to be rec-connected with the
needed quality of life as per the kingdom vision for 2030. The landscape area
in healthcare buildings need to be around 50% of the total area given for the
hospital. This area needs carful design and connection with the activities
needed in this kind of buildings.

Humans’ wellbeing means both mental and physical health condition. In this
paper, it focuses on landscape importance to improve mental health, which
leads to enhancing physical health, especially in hospitals. A survey con­
ducted for patients to show their thoughts about landscape design influences
                                                               HBRC JOURNAL     531

in hospitals, which has shown that most would prefer hospitals that their
landscape is well designed; this proves that greenery affects mental health
and support the idea of implementing greenery in hospitals as part of the
treatment process. Three points support this result:

   ● The relation between landscaping and hospital functionality as men­
     tioned in point (1.1).
   ● Different types of greenery and its influences on patients as mentioned
     in point (1.2).
   ● Possibility of using landscape and greenery as part of the patients’
     treatment as mentioned in point (1.3).

   Additionally, researchers can examine this result and support it to improve
hospitals’ quality over the world. The green area reached approximately 50%
of the total hospital area in the above-mentioned case study. This can be
reevaluated based on the functionality of the landscape areas and the
needed impression patients do need for the healing process. The way to
implement greenery in the treatment of patients also needs to be illustrated
in future studies. It is concluded that normal vegetation and healing centers
scene play a crucial part in wellbeing of patients through different physical,
mental, and social benefits. As well, evidence from ponders of several respon­
dents unequivocally recommends that gardens and other natural component
help move forward patient’s fulfillment with the execution of healthcare
supplier and by large quality of care. Landscaping area in hospitals plays
a major role in the healing process of patients in hospitals and workers.
   Existing areas around hospitals might be revisited and redesigned to sup­
port the ultimate kingdom goal toward 2030 vision in raising the quality of life.
   Other hospitals can be analyzed and the landscape area to be calculated
and determined according to the hospital type.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Asmaa Ramadan Elantary

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